NCC204439_NOI Application_20201215

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 10/1/2020 4:49:37 PM (NCG01 NOI Submission)
Approve by Garcia, Lauren V 10/5/2020 9:08:28 AM (Review- Construction NOI 32436)
• The task was assigned to Garcia, Lauren V by round robin distribution 10/1/2020 4:50 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: October 5, 2020 5:00
PM 10/1/2020 4:50 PM
Submit by Selkane, Aziza 12/15/2020 9:05:28 AM (Payment Verification for NCC204439)
* FLB Construct WC Construct
• Selkane, Aziza assigned the task to Selkane, Aziza 12/15/2020 9:04 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: November 16, 2020 5:00
PM 10/5/2020 9:08 AM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
Are you submitting IT No
an NOI that was r Yes
rejected before?
1a. Project Name * Bowman Gray Stadium
1 b. Specific Lot This field rray be used to list specifc lot nunbers.
Numbers
1 c. Parcel ID List all Ait associated w ith this project.
Number(s) (PIN)
2. County* Forsyth
3. Highway or Street 1250 S Martin Luther King Jr Dr
Address* Street name only is acceptable if no address nunber assigned yet
4. Cityor Township* Winston-Salem
5. State * NC
6. Zip Code* 27107
7. Latitude* Enter the latitude in decinal degrees
36.0827
8. Longitude * Enter the longitude in decinal degrees (MJSTbe negative)
-80.2221
If you do not know the latitude and longitude coordinates for this project, you can search the location on this map of
North Carolina. Look for the coordinates in the bottom left corner.
9. Date to Begin*
11/02/2020
Estirrated Construction Project Start Rate
10. Date to End*
03/31/2022
Estimated Construction Project End Date
11. SIC (Primary) *
Other (9999)
Standard Industrial C]assification for Development
12. Acres to be
5.60
disturbed*
(including off -site borrow and waste areas)

13. Total site area 33.56
(acres) *
14. Post- 19.10
construction (Estirreted)
impervious area
(acres) *
NCC Project NCC-FORSY-2020-Bowman Gray Stadium
Tracking ID Assigned automatically
Below you must enter waterbody information for surface waters affected by this project. Please consult
DWR's Surface Water Classifications Map Viewer to find waterbody name and corresponding index number. Please
enter only immediate receiving waterbodies - not waters downstream of those unless the project extends there. You
may enter up to 3 waterbodies if needed.
15a. Receiving Salem Creek (Middle Fork Muddy Creek)
Wate rbody* f\brre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 12-94-12-(4)
Index No.* NCWaterbody Index I inber
Stormwater V No
discharges will flow r Yes
to additional
wate rs *
16a. Is this project r Yes
subject to the NC r No, not subject to NC SPCA
Sediment Pollution
Control Act?*

B. Permittee Information
Part B. ^
Fternittee Inforrration - Legally Fbsponsible Entity and Individual
Important: The person who signs the NOI Certification Form and signs the Certification in Section E of this application
form should be the same person as listed in THIS SECTION, or an authorized responsible individual within the same
organization. That person must be a responsible corporate officer who owns or operates the construction activity, such
as a president, secretary, treasurer, or vice president, or a manager that is authorized in accordance with Part IV,
Section B, Item (6) of the NCG010000 General Permit. For more information on signatory requirements, see Part
IV, Section B, Item (6) of that permit.
1. Organization Legally Pesponsible Entity
Name * City of Winston-Salem
It pernittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
Note: The organization name must match the business entity name registered with the NC Secretary of State. You can
verify the registration here.
2. First Name * Lee
If Corporation, enter Faegistered Agent First %rre
3. Last Name* Garrity
It Corporation, enter Pbegistered Agent Last %rre
3b. Title City Manager
4. Permitee E-mail [e-mail]
Address*
5. Permittee 336-747-7380
Telephone No.*
6. Permittee Mailing Street Address
Address* PO Box2511
Address Line 2
City
Winston-Salem
Fbstal / Zip Code
27101
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
F Yes
Street Address
101 North Main Street
Address Line 2
Suite 170
city
Winston-Salem
Fbstal / Zip Code
27101
State / Ffovince / Fbgion
NC
Country
us
State / Frovince / Region
NC
Country
us
8. Type of Ownership is only individual if an individual is naned in B.1. above.
Ownership* Government -Municipal

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Trey
Contact - First
Name *
2. Primary Site
Lambert
Contact - Last
Name *
3. Title
Site Superintendant
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
336-724-5528
Telephone No.
6. Organization
Frank L. Blum
Name
7. Site Contact
Street Address
Mailing Address*
830 East 25th Street
Address Line 2
City
Winston-Salem
Fbstal / Zip Code
27105
8. Consultant Name
(Optional)
Kevin Davie
First and Last narre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
336-397-1217
Telephone No.
State / Rovince / Region
NC
Country
us

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 09/15/2020
Approved *
2. E&SC Plan Project forsy-2021-007
Number/ID * Assigned by agency or local program
3. E&SC Plan r State DEQ Office
Approved by* r Local Program
4. State DEQ Office * Winston-Salem (WSRO)
Documentation of E&SC Plan approval and the signed Notice of Intent (NOI) Certification Form is required for a
complete application. For linear projects, please also upload a site map showing the overall extent of the project or
include the beginning point and end point coordinates in the "Notes" box below.
5. E&SC Plan 20200921 Scan_DEMLR Permit.PDF 50.18KB
Approval letter or Mast beRDFformat
Grading Permit
6. Site Location Map Mist be RDFforrret (lint 20 NB)
VC.pdf 29.91 KB
Rease do not upload entire set of E&SC plans.
7. Notes (Optional) Rovide any additional information that night help the reviewer better understand how uploaded docurrents support
the application. Include additional waterbodies for linear projects if necessary.
8. NOI Certification 2020-09-29 eNO1 Scan_09302020114625.PDF 383.58KB
Form Wst be RDFforrret
This is an Express r No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.66 (1) provides that:
Any person who knowingly makes anyfalse statement, representation, or certification in any application, record, report, plan, or other
document filed or required to be maintained under this Article or a rule implementing this Article; or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case under this Artcle; or who falsifies, tampers with, or knowingly renders
inaccurate any recording or monitoring device or method required to be operated or maintained under this Article or rules of the
Commission implementing this Artcle shall be guilty ofa Class 2 misdemeanor which may include a fine not to exceed ten thousand
dollars ($10,000).
Under penalty of law, I certify that:
17 I am the person responsible for the construction activities of this project, for
satisfying the requirements of this permit, and for any civil or criminal penalties
incurred due to violations of this permit.
rJ The information submitted in this NOI is, to the best of my knowledge and belief,
true, accurate, and complete based on my inquiry of the person or persons who
manage the system, or those persons directly responsible for gathering the
information.
* 17 I will abide by all conditions of the NCG010000 General Permit and the
approved Erosion and Sediment Control Plan.
* rJ I hereby request coverage under the NCG010000 General Permit and
understand that coverage under this permit will constitute the permit
requirements for the discharge(s) and is enforceable in the same manner as an
individual permit.
Specify if you are:* r The Legally Responsible Person named on this Notice of Intent
f Authorized Responsible Person* (signing on behalf of Legally Responsible
Person named in Part B)
Important: The person who electronically signs this Certification above must be the same person who signs the NOI
Certification Form. If that person is signing on behalf of the Permittee, that individual must be an authorized responsible
person within the same organization as the Permittee. *An authorized individual is a responsible corporate officer who
owns or operates the construction activity, such as a president, secretary, treasurer, or vice president, or a manager
that is authorized in accordance with Part IV, Section B, Item (6) of the NCG010000 General Permit. For more
information on signatory requirements, see Part IV, Section B, Item (6) of that permit.
Signature
Type Name* Lee Garrity
Title City Manager
Organization Legally Plesponsible Entity
City of Winston-Salem
Date * 10/01 /2020

F. Tracking and COC Info
NOI Tracking No. 32436
NC Reference No.
NCG01-2020-4439
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC204439
Coverage (COC)
Uses 'count number' variable (increrrented by SP)
No.*
Count Number 4439
Sequential nurrber for subrrittal that is incremented by Stored Frocedure
COC Year 2020
Year of date reviewed (used to assign YY digits after "NOC' in COCno.)
Initial Invoice No. NCC204439-2020
Invoice Due Date 11/4/2020
Initial Fee $ 100.00
Invoice Status OPEN